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Mycobacterium Abscessus Lung Infection Associated With Achalasia
Chest Infections SESSION TITLE: Student/Resident Case Report Poster - Chest Infections I SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM
Mycobacterium Abscessus Lung Infection Associated With Achalasia Bhisham Harchandani MBBS* Adam Austin MD; and Richard Blinkhorn MD Albany Medical Center, Albany, NY INTRODUCTION: Presenting a case of atypical mycobacterium in a patient with achalasia and challenges in its diagnosis and treatment. CASE PRESENTATION: A 36-year-old man with Achalasia Cardia since his youth presented with 6 month history of nonproductive cough and 3 week history of fever, chills and dysphagia prior to admission. Esophagogram revealed severe achalasia. He underwent Heller myotomy and fundoplication with resolution of his dysphagia. During this hospitalization he also had left lower lobe consolidation consistent with aspiration. He was subsequently discharged on oral antibiotics. He was readmitted two weeks later with worsening cough and an enlarging left lower lobe organizing pneumonia. Due to a suspicion of cryptogenic organizing pneumonia (COP), he was initially treated with prednisone with improvement in symptoms. A sputum culture grew acid fast bacilli subsequently identified as Mycobacterium abscessus positive for erm(41) gene. Bronchoalveolar lavage and multiple additional sputum samples were AFB culture-negative. Steroids were continued for suspected COP with symptomatic improvement but without radiologic improvement. Percutaneous lung biopsy revealed necrotizing granulomatous inflammation; smears and culture negative for AFB. Tigecycline, linezolid and amikacin were administered in preparation for planned surgical resection. Follow up chest CT two months into therapy showed persistent but decreasing size of the lower lobe consolidation. DISCUSSION: Rapidly growing mycobacterium species are known to be associated with esophageal disorders, especially achalasia [1]. Mycobacterium abscessus infection although rare, has been previously described in this setting. The recently discovered presence of erm(41) gene activity confers inducible resistance to macrolides antibiotics [2], a mainstay of treatment for many nontuberculous mycobacteria. There is no rigorously established chemotherapy for M abscessus, and regimens currently recommended have a high incidence of adverse effects. Surgery is frequently advocated if feasible [3].
Reference #1: Hadjiliadis, D., A. Adlakha, and U.B. Prakash, Rapidly growing mycobacterial lung infection in association with esophageal disorders. Mayo Clin Proc, 1999. 74(1): p. 45-51. Reference #2: Nash, K.A., B.A. Brown-Elliott, and R.J. Wallace, Jr., A novel gene, erm(41), confers inducible macrolide resistance to clinical isolates of Mycobacterium abscessus but is absent from Mycobacterium chelonae. Antimicrob Agents Chemother, 2009. 53(4): p. 1367-76. Reference #3: Jarand, J., et al., Clinical and microbiologic outcomes in patients receiving treatment for Mycobacterium abscessus pulmonary disease. Clin Infect Dis, 2011. 52(5): p. 565-71. DISCLOSURE: The following authors have nothing to disclose: Bhisham Harchandani, Adam Austin, Richard Blinkhorn No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.182
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
journal.publications.chestnet.org
173A
CHEST INFECTIONS
CONCLUSIONS: Rapidly growing mycobacteria in aspiration syndromes are associated with achalasia and other related esophageal motility disorders. Our case demonstrates the challenges a clinician may encounter in establishing a diagnosis versus the more traditional microbial causes for aspiration pneumonitis.
Mycobacterium Abscessus Lung Infection Associated With Achalasia Bhisham Harchandani MBBS* Adam Austin MD; and Richard Blinkhorn MD Albany Medical Center, Albany, NY INTRODUCTION: Presenting a case of atypical mycobacterium in a patient with achalasia and challenges in its diagnosis and treatment. CASE PRESENTATION: A 36-year-old man with Achalasia Cardia since his youth presented with 6 month history of nonproductive cough and 3 week history of fever, chills and dysphagia prior to admission. Esophagogram revealed severe achalasia. He underwent Heller myotomy and fundoplication with resolution of his dysphagia. During this hospitalization he also had left lower lobe consolidation consistent with aspiration. He was subsequently discharged on oral antibiotics. He was readmitted two weeks later with worsening cough and an enlarging left lower lobe organizing pneumonia. Due to a suspicion of cryptogenic organizing pneumonia (COP), he was initially treated with prednisone with improvement in symptoms. A sputum culture grew acid fast bacilli subsequently identified as Mycobacterium abscessus positive for erm(41) gene. Bronchoalveolar lavage and multiple additional sputum samples were AFB culture-negative. Steroids were continued for suspected COP with symptomatic improvement but without radiologic improvement. Percutaneous lung biopsy revealed necrotizing granulomatous inflammation; smears and culture negative for AFB. Tigecycline, linezolid and amikacin were administered in preparation for planned surgical resection. Follow up chest CT two months into therapy showed persistent but decreasing size of the lower lobe consolidation. DISCUSSION: Rapidly growing mycobacterium species are known to be associated with esophageal disorders, especially achalasia [1]. Mycobacterium abscessus infection although rare, has been previously described in this setting. The recently discovered presence of erm(41) gene activity confers inducible resistance to macrolides antibiotics [2], a mainstay of treatment for many nontuberculous mycobacteria. There is no rigorously established chemotherapy for M abscessus, and regimens currently recommended have a high incidence of adverse effects. Surgery is frequently advocated if feasible [3].
Reference #1: Hadjiliadis, D., A. Adlakha, and U.B. Prakash, Rapidly growing mycobacterial lung infection in association with esophageal disorders. Mayo Clin Proc, 1999. 74(1): p. 45-51. Reference #2: Nash, K.A., B.A. Brown-Elliott, and R.J. Wallace, Jr., A novel gene, erm(41), confers inducible macrolide resistance to clinical isolates of Mycobacterium abscessus but is absent from Mycobacterium chelonae. Antimicrob Agents Chemother, 2009. 53(4): p. 1367-76. Reference #3: Jarand, J., et al., Clinical and microbiologic outcomes in patients receiving treatment for Mycobacterium abscessus pulmonary disease. Clin Infect Dis, 2011. 52(5): p. 565-71. DISCLOSURE: The following authors have nothing to disclose: Bhisham Harchandani, Adam Austin, Richard Blinkhorn No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.182
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
journal.publications.chestnet.org
173A
CHEST INFECTIONS
CONCLUSIONS: Rapidly growing mycobacteria in aspiration syndromes are associated with achalasia and other related esophageal motility disorders. Our case demonstrates the challenges a clinician may encounter in establishing a diagnosis versus the more traditional microbial causes for aspiration pneumonitis.